University of Utah Health Insurance Plans

Healthy Premier Silver 2300

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $2,300.00 Family: $4,600 Per Person: $2,300
Prescription Drug Deductible	Individual: $1,000.00 Family: $2,000 Per Person: $1,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,300.00 Family: $16,600 Per Person: $8,300

Office Visit

Primary Doctor	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Requires Pre-authorization and Medical Case Management.
Inpatient Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Requires Pre-authorization and Medical Case Management.

Emergency and Urgent Care

Emergency Room	CoPay: $600.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Benefit Period

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered

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